Impact of Health Literacy in Disease Activity, Medications in Rheumatoid Arthritis

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Patients with “good health literacy” had significantly lower disease activity over time than those with “several health literacy limitations,” adjusting for age, gender and education level.

Health literacy is an important social determinant of health which includes personal competencies and resources that are needed for individuals to access, understand, and use health information and services to make decisions about their health.1 Limited health literacy has been shown to be associated with worse health outcomes, including lower medication adherence, problems seeking preventive care, and poorer health outcomes.

A recent study by Gorter and Bakker et al sought to build upon previous work identifying 10 distinct health literacy profiles of patients with rheumatic diseases, categorizing them based on strengths and weaknesses related to their health literacy.2 The aim of the study was to explore longitudinal associations between health literacy profiles, disease activity and medication prescription in patients with rheumatoid arthritis (RA).

The study enrolled 108 patients with RA at a hospital in the Netherlands who previously completed the Health Literacy Questionnaire (HLQ) in 2019. They retrieved up to 1 year of follow-up data on disease activity and medication prescription from the electronic health record.Disease activity was assessed using Disease Activity Score-28 for Rheumatoid Arthritis with erythrocyte sedimentation rate (DAS28-ESR) scores. Medication prescription information was also retrieved.Linear mixed modelling was used to analyze association between health literacy groups and disease activity over 1 year. To compare medication prescription use between groups, Chi squared tests and logistic regression analysis were used.

The study found 21 patients had “several health literacy limitations,” 33 had “some health literacy limitations,” and 54 had “good health literacy.” The mean age was 66 years and 62% of the cohort were female; around half of patients were seropositive (rheumatoid factor [RF] 57%, cyclic citrullinated peptide [CCP] 54%). The linear mixed modelling showed significant effect of health literacy group on DAS28-ESR scores over time. Patients with “good health literacy” had significantly lower disease activity over time than those with “several health literacy limitations,” adjusting for age, gender, and education level. Interestingly, patients with “good health literacy” were most often prescribed a biologic DMARD (50%), whereas those with “some health literacy limitations” more commonly received a conventional synthentic disease-modifying antirheumatic drugs (csDMARDs) only (72.7%, odds ratio [OR] 4.24), and those with “several health literacy limitations” were more often prescribed steroids (52.4%, OR 3.56).

The authors explained how their results demonstrated patients with more health literacy needs had higher disease activity over time, independent of their education level.An intriguing finding was that patients with “several health literacy limitations” were prescribed prednisolone more often, which they postulate may be due to insufficient control of disease activity or patients with more health literacy needs asking for prednisolone more often. They found significantly more biologic DMARD (bDMARD) prescriptions in the “good health literacy” group, which could be due to reluctance amongst patients with lower health literacy to change therapy or having more concerns about bDMARDs.

They also highlighted some limitations, including need to replicate their findings, due to the small size of the groups, grouping different health literacy profiles into 3 groups analyzed, and the homogeneity of the population from a specific region of the Netherlands.

Finally, the authors of this article raised suggestions on how to “level the playing field” through health literacy, noting health literacy is a modifiable determinant of health but hard to improve within the limited timeframe of a clinic visit. They suggested improving our services to better respond to health literacy limitations of our patients, such as using understandable and actionable information materials (including plain language and illustrations) and offering patients additional guidance and support. Another suggestion was to use a “universal precautions” approach, assuming every patient is at risk of reduced access to care and potentially poor outcomes of care due to limited health literacy.

This study highlights the influence of health literacy in outcomes of patients with RA and even potential implications in specific DMARD therapy selection, and why rheumatologists should be aware of the impact of health literacy in clinical care.


  1. Broder J, Chang P, Kickbusch I et al. IUHPE position statement on health literacy: a practical vision for a health literate world. Glob Health Promot, 2018.
  2. Gorter A, Bakker MM, Ten Klooster PM. The impact of health literacy: associations with disease activity and medication prescription in patients with rheumatoid arthritis. Rheumatology, 2023.